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COMMENTARY: Suggestions on reforming health care
By Mike LeSueur
Like many of my physician colleagues, I agree with our president. Our health care system is broken. But the recently passed heath care reform bill seems to overlook many of our current problems and frustratingly creates new ones. The fix needs fixing. President Obama has asked us to make suggestions and here are some of mine. They are not detailed but of a general or maybe even a philosophical nature that I believe will help us provide basic quality health care at an affordable cost.
1. To help keep mandatory medical insurance affordable it should provide for basic services only. Cosmetic procedures, certain elective abortions, and services with little or no efficacy should not be included but be available on a fee for service or additional insurance basis. These controversial decisions should be made by a non-partisan, lobbyist-immune panel with primary consideration given to cost vs. benefit; affordability vs. desirability.
2. When there are no disincentives to prevent it, people will flood emergency rooms with non-emergent conditions such as chapped lips, sunburn, and ingrown toe nails, which contributes to long ER waits and waste of resources. Disincentives that help prevent waste of our limited medical resources need to be part of our health care reform and until those are in place, please don't expand Medicaid or free coverage.
3. Health care should not be linked to employment. We should not have to change health insurance and doctors when we change employment. That model decreases continuity and quality of care, is expensive to administer, and leads to duplication of services. In addition, when we link health care coverage to employment, we encourage unemployment, and part-time jobs with lower incomes. The Lewin Group predicted that the Health Care Reform Act would result in the loss of between 260,000 and 600,000 jobs nationwide. <http://www.lewin.com/content/publications/LewinAnalysisHouseBill2009.pdf>
4. Unreasonable limits on medical school admissions create inflationary doctor shortages in many parts of the country. Many of our residency slots are taken by foreign medical graduates because we don't graduate enough of our own doctors. Every year potential American doctors are forced into other careers by unreasonable limits on medical school admissions. In 2007 the United States had 2.43 practicing physicians per 1,000 population, which is significantly less than most other OECD countries. It stands to reason that if you increase coverage you must increase the number of providers.
5. Underwriting policies that prevent people from obtaining affordable insurance should be outlawed, but remember that some underwriting policies serve the worthwhile purpose of encouraging healthy choices. Don't throw the baby out with the bathwater. There should be a way for those who consume more health care because of their lifestyles to help pay for those extra costs. We charge high sales tax on tobacco products and those dollars could and should go to defray the costs of medical care. Health care reform should find creative ways to make those who opt for unhealthy life styles financially responsible for their choices.
6. Cost control could and should come from tort reform. The current tort system is a huge driver of runaway health care costs and doctor shortages. Forty percent of my class, most of whom are in their early 60s, is now retired in part because they are at a stage of life where they can't afford to lose everything because they refused to settle a lawsuit. If they don't settle, they are personally liable for any damages a jury may award above the limits of their insurance. There are more effective and responsible ways to encourage quality care and to see that those who are injured by malpractice are reasonably compensated. California and Texas have passed limits on awards for pain and suffering and the cost of medical liability insurance has dropped dramatically. Liability insurance expenses are second only to payroll for most physicians. Cutting physician, pharmacy, and hospital payments to keep health care costs at bay will be a more realistic option if their liability expenses are also cut. If we are going to address runaway health care costs, tort reform must be in the mix.
7. Seventy percent of our health care expenses are incurred by 10 percent of the population, and much of that expense is incurred in the final year or month of life. Obviously, if we are to significantly reduce health care costs, this must be addressed. Our current fee for service incentives and lack of advanced medical directives only serve to drive this phenomenon. Physicians need to be better trained in the ethics and art of end-of-life care. Patient and family education can greatly improve quality of life in its final stages and at the same time reduce costs.
Controlling health care expenditures is a formidable task that will require trade-offs. It won't be accomplished unless we address tort reform, irresponsible health care consumption, disincentives and education for unhealthy life styles, limits on admissions to medical schools, end-of -life care, and so on. As far as I can tell, the current bill does not address most of these issues - mainly it's about insurance reform. It appears that we have passed insurance reform without addressing health care reform, and we are going to be stuck with a system that fosters a dole, encourages unemployment, and increases costs instead of decreasing them. As this bill is fine tuned over the next several months and years, we need members of Congress to say "no" to their special interest groups, and address these tough problems. We need them to fix our broken system without further contributing to our financial woes.
Dr. Mike LeSueur retired in 2007. He held a Benson medical practice 25 years.
1. To help keep mandatory medical insurance affordable it should provide for basic services only. Cosmetic procedures, certain elective abortions, and services with little or no efficacy should not be included but be available on a fee for service or additional insurance basis. These controversial decisions should be made by a non-partisan, lobbyist-immune panel with primary consideration given to cost vs. benefit; affordability vs. desirability.
2. When there are no disincentives to prevent it, people will flood emergency rooms with non-emergent conditions such as chapped lips, sunburn, and ingrown toe nails, which contributes to long ER waits and waste of resources. Disincentives that help prevent waste of our limited medical resources need to be part of our health care reform and until those are in place, please don't expand Medicaid or free coverage.
3. Health care should not be linked to employment. We should not have to change health insurance and doctors when we change employment. That model decreases continuity and quality of care, is expensive to administer, and leads to duplication of services. In addition, when we link health care coverage to employment, we encourage unemployment, and part-time jobs with lower incomes. The Lewin Group predicted that the Health Care Reform Act would result in the loss of between 260,000 and 600,000 jobs nationwide. <http://www.lewin.com/content/publications/LewinAnalysisHouseBill2009.pdf>
4. Unreasonable limits on medical school admissions create inflationary doctor shortages in many parts of the country. Many of our residency slots are taken by foreign medical graduates because we don't graduate enough of our own doctors. Every year potential American doctors are forced into other careers by unreasonable limits on medical school admissions. In 2007 the United States had 2.43 practicing physicians per 1,000 population, which is significantly less than most other OECD countries. It stands to reason that if you increase coverage you must increase the number of providers.
5. Underwriting policies that prevent people from obtaining affordable insurance should be outlawed, but remember that some underwriting policies serve the worthwhile purpose of encouraging healthy choices. Don't throw the baby out with the bathwater. There should be a way for those who consume more health care because of their lifestyles to help pay for those extra costs. We charge high sales tax on tobacco products and those dollars could and should go to defray the costs of medical care. Health care reform should find creative ways to make those who opt for unhealthy life styles financially responsible for their choices.
6. Cost control could and should come from tort reform. The current tort system is a huge driver of runaway health care costs and doctor shortages. Forty percent of my class, most of whom are in their early 60s, is now retired in part because they are at a stage of life where they can't afford to lose everything because they refused to settle a lawsuit. If they don't settle, they are personally liable for any damages a jury may award above the limits of their insurance. There are more effective and responsible ways to encourage quality care and to see that those who are injured by malpractice are reasonably compensated. California and Texas have passed limits on awards for pain and suffering and the cost of medical liability insurance has dropped dramatically. Liability insurance expenses are second only to payroll for most physicians. Cutting physician, pharmacy, and hospital payments to keep health care costs at bay will be a more realistic option if their liability expenses are also cut. If we are going to address runaway health care costs, tort reform must be in the mix.
7. Seventy percent of our health care expenses are incurred by 10 percent of the population, and much of that expense is incurred in the final year or month of life. Obviously, if we are to significantly reduce health care costs, this must be addressed. Our current fee for service incentives and lack of advanced medical directives only serve to drive this phenomenon. Physicians need to be better trained in the ethics and art of end-of-life care. Patient and family education can greatly improve quality of life in its final stages and at the same time reduce costs.
Controlling health care expenditures is a formidable task that will require trade-offs. It won't be accomplished unless we address tort reform, irresponsible health care consumption, disincentives and education for unhealthy life styles, limits on admissions to medical schools, end-of -life care, and so on. As far as I can tell, the current bill does not address most of these issues - mainly it's about insurance reform. It appears that we have passed insurance reform without addressing health care reform, and we are going to be stuck with a system that fosters a dole, encourages unemployment, and increases costs instead of decreasing them. As this bill is fine tuned over the next several months and years, we need members of Congress to say "no" to their special interest groups, and address these tough problems. We need them to fix our broken system without further contributing to our financial woes.
Dr. Mike LeSueur retired in 2007. He held a Benson medical practice 25 years.
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The following are comments from the readers. In no way do they represent the view of bensonnews-sun.com.
Phillip D wrote on Feb 3, 2010 6:33 PM:
" Dr. LeSuer,
Thank you for sharing your wisdom and insight regarding health care reform and potential costs. I agree strongly with several of your points, but one in particular is screaming out for some correction.
Tort reform takes away our 7th Amendment Right guaranteed in Constitution. As one of the original Bill Of Rights, it is no less sacred and sacrosanct than the 1st or 2nd Amendments, and I would not cast it aside as cavalierly as you do, especially when the cost reductions are not what you suggest they will be.
Over half our states have now instituted some kind of tort reform, and health care costs have not gone down and doctors are still practicing "defensive" medicine (because it's profitable!). All it has done is protect insurance company profits, and it has not lowered costs of health care in states like Texas, as you suggest.
Texas instituted tort reform in 2003. The problem with what you suggest is that health care costs in Texas not only continued to rise after 2003, but they rose more than in most of the rest of the country. In 2008, the Robert Wood Johnson Foundation found that Texans enjoyed the third fastest increase in health insurance premiums in the nation. And for many years Texas has led the nation in the percentage of its citizens without health insurance. The 2003 tort reform didn't change that. Maybe doctor premiums went down for their liability insurance, but doctor costs are not what we are worried about.
The second issue is minor -- #3. I agree that health insurance should not be tied to employment, but not because the Lewin Group said jobs will be lost. Remember, the Lewin Group is a subsidiary of United Health Care - the Insurance Company. They are the last place you would look to find an unbiased, fair citation to support your point. If insurance is paid for and provided as a single payer system, rather than being tied to employment, it will be much more sensible, equitable, just and cost effective. "
Thank you for sharing your wisdom and insight regarding health care reform and potential costs. I agree strongly with several of your points, but one in particular is screaming out for some correction.
Tort reform takes away our 7th Amendment Right guaranteed in Constitution. As one of the original Bill Of Rights, it is no less sacred and sacrosanct than the 1st or 2nd Amendments, and I would not cast it aside as cavalierly as you do, especially when the cost reductions are not what you suggest they will be.
Over half our states have now instituted some kind of tort reform, and health care costs have not gone down and doctors are still practicing "defensive" medicine (because it's profitable!). All it has done is protect insurance company profits, and it has not lowered costs of health care in states like Texas, as you suggest.
Texas instituted tort reform in 2003. The problem with what you suggest is that health care costs in Texas not only continued to rise after 2003, but they rose more than in most of the rest of the country. In 2008, the Robert Wood Johnson Foundation found that Texans enjoyed the third fastest increase in health insurance premiums in the nation. And for many years Texas has led the nation in the percentage of its citizens without health insurance. The 2003 tort reform didn't change that. Maybe doctor premiums went down for their liability insurance, but doctor costs are not what we are worried about.
The second issue is minor -- #3. I agree that health insurance should not be tied to employment, but not because the Lewin Group said jobs will be lost. Remember, the Lewin Group is a subsidiary of United Health Care - the Insurance Company. They are the last place you would look to find an unbiased, fair citation to support your point. If insurance is paid for and provided as a single payer system, rather than being tied to employment, it will be much more sensible, equitable, just and cost effective. "
Mike wrote on Feb 4, 2010 8:33 PM:
" Phil,
You are spot on about the Lewin Group. It is an Ingenix company which is a wholly-owned subsidiary of United Health Group, and even though they claim “editorial independence” they will always be susceptible to claims of bias on this subject. But even though their numbers may reflect bias, their assessment, and I think that of most Americans, is that giving employers a mandate to provide health care insurance to all their employees cannot help but contribute to unemployment. I believe you said that you agree that health insurance shouldn’t be linked to employment but not necessarily for the unemployment reason.
As you said, tort reform in California and Texas has not resulted in a decrease in health care costs, but that is only because many other factors besides liability insurance are driving those costs. I think it is undeniable that liability insurance is a major expense for physicians, hospitals, and pharmaceutical companies. We can expect, even demand that we get quality care at a reduced cost if we also reduce expenses by passing tort reform. There is no constitutional right to unlimited awards for “pain and suffering". We are not talking about abolishing the tort system, just reforming it in an attempt to make health care affordable to all.
Mike "
You are spot on about the Lewin Group. It is an Ingenix company which is a wholly-owned subsidiary of United Health Group, and even though they claim “editorial independence” they will always be susceptible to claims of bias on this subject. But even though their numbers may reflect bias, their assessment, and I think that of most Americans, is that giving employers a mandate to provide health care insurance to all their employees cannot help but contribute to unemployment. I believe you said that you agree that health insurance shouldn’t be linked to employment but not necessarily for the unemployment reason.
As you said, tort reform in California and Texas has not resulted in a decrease in health care costs, but that is only because many other factors besides liability insurance are driving those costs. I think it is undeniable that liability insurance is a major expense for physicians, hospitals, and pharmaceutical companies. We can expect, even demand that we get quality care at a reduced cost if we also reduce expenses by passing tort reform. There is no constitutional right to unlimited awards for “pain and suffering". We are not talking about abolishing the tort system, just reforming it in an attempt to make health care affordable to all.
Mike "
Gus wrote on Feb 3, 2010 2:34 PM: